Gliederung

Objective

Closed continuous lumbar drainage of crebrospinal fluid (CSF) has been used in neurosurgery for a variety of reasons. The use of lumbar drainage in uncontrollable intracranial hypertension was considered to be contraindicated because of the possibility of inducing transtentorial or tonsillar herniation. The objective of these study was to investigate the effect of continuous external lumbar CSF drainage on intracranial pressure (ICP) and to evaluate the potential side effects of these new therapeutic modality in adult patients suffering sustained therapy-resistant intracranial hypertension.

Methods

From 2/1998 to 11/2003, prospective evaluation of 68 patients (age 42Â±17 yrs) with therapy-resistant ICP increase following severe traumatic brain injury (TBI) (n=28) or severe subarachnoid hemorrhage (SAH) (n=40) was carried out. Patients were considered for external lumbar fluid drainage if they suffered persistent intracranial hypertension of values more than 25 mmHg for a period of more than 15 minutes and failed to respond to high intensity treatment. External lumbar drainage was not performed in patients with tight basal cisterns. After institution of the lumbar drain (silicon-catheter, Touhy type needle) aspiration of 5 to 20 ml CSF was performed and continuous CSF-drainage was maintained. ICP and CPP before and after bolus-aspiration was documented. The neurological outcome of the patients was scored according to the Glasgow Outcome Scale (GOS) at discharge.

Results

All patients showed a significant decrease of ICP from 33.4Â±9.8 mmHg to 13.7Â±5.4 mmHg and an increase of CPP from 67.3Â±18.8 mmHg to 85.6Â±13.3 mmHg. Two patients showed a unilateral dilated and fixed pupil. In patients suffering from SAH two (5%) showed a favorable outcome (GOS 4/5), 13 patients (33%) survived with a severe permanent neurological deficit (GOS 3), 5 patients (12%) remained in a persistent vegetative state (GOS 2) and 20 patients (50%) died (GOS 1). In TBI patients four (14%) showed a GOS 4/5, twelve patients (43%) presented with a GOS 3, five (18%) patients with a GOS 2 and seven patients (25%) died.

Conclusions

Controlled external lumbar drainage reduces therapy-resistant intracranial hypertension significantly. However, our results indicate that patients with TBI benefit from lumbar CSF drainage whereas in patients suffering from SAH the control of ICP doesnÂ´t lead to an improved outcome. The hazard of transtentorial or tonsillar herniation might be limited by considering lumbar drainage only in the presence of discernible basilar cisterns.